1972002301 NPI number — MD NUTRITION AND LIFESTYLE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972002301 NPI number — MD NUTRITION AND LIFESTYLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MD NUTRITION AND LIFESTYLE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972002301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 BRETTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-796-1930
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5901 KINGSTOWNE VILLAGE PKWY
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
KINGSTOWNE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-796-1930
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
MARA
Authorized Official Middle Name:
MICHELE
Authorized Official Title or Position:
CLINICAL DIETITAN
Authorized Official Telephone Number:
860-796-1930

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  001415 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: L002913 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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